Concussion Symptoms?

Which of These Physical Symptoms Are You Experiencing?

Please Select All That Apply*

Loss of ConsciousnessFatigue or DrowsinessSleeping More Than UsualDizziness or Loss of BalanceDilation of One or Both PupilsLoss of CoordinationNausea or VomitingConvulsions or SeizuresDifficulty SleepingInability to Wake From SleepNumbness in Fingers or ToesPersistent or Worsening HeadacheNoneOther

Which of These Sensory Symptoms Are You Experiencing?

Please Select All That Apply*

Blurred VisionSensitivity to LightBad Taste in MouthRinging in EarsChanging in Ability to SmellSensitivity to SoundNone

Which of These Cognitive or Mental Symptoms Are You Experiencing?

Please Select All That Apply*

Problem w/ MemoryConcentration ProblemsMood Changes or SwingsSlurred SpeechFeeling Anxious or DepressedComaConsciousness DisorderNO SYMPTOMS

Date of Incident?

On what date did your possible head injury occur?*

More About Your Head Injury...

What do You Believe Caused Your Head Injury? *Auto AccidentSlip & FallSports InjuryOtherUnsure

Have You Visited a Doctor Regarding Your Head Injury *YESNO

Have You Consulted w/ an Attorney Regarding Your Auto Accident? *YESNO

What Is Your Preferred Method of Communication? *Phone (Call)Phone (Text)EmailNo Preference